Looking to book a COVID-19 PCR Test? Book Now

How to Treat Hypertension General?


Things to note:
Lifestyle modification
All persons with hypertension should be encouraged to make the following lifestyle changes as appropriate.
  • Smoking cessation.
  • Maintain ideal weight, i.e. BMI <25 kg/m2. Weight reduction in the overweight patient.
  • Salt restriction with increased potassium intake from fresh fruits and vegetables (e.g. remove the salt from the table, gradually reduce added salt in food preparation and avoid processed foods).
  • Reduce alcohol intake to no more than 2 standard drinks per day for males and 1 for females.
  • Follow a prudent eating plan i.e. low fat, high fibre and unrefined carbohydrates, with adequate fresh fruit and vegetables.
  • Regular moderate aerobic exercise, e.g. 30 minutes brisk walking at least 3 times a week.

Medical Treatment:
  • Initial drug choice in patients qualifying for treatment is dependent on the presence of compelling indications.
Note:
  • Check adherence to antihypertensive therapy.
  • Monitor patients monthly and adjust therapy if necessary until the BP is controlled. After target BP is achieved, patients can be seen at 3-6 monthly intervals.
Medicine choices without compelling indications

Low risk: BP <160/100 mmHg, no risk factors, Target organ damage (TOD) or associated clinical condition (ACC).
  • Lifestyle modification for 3-6 months.
  • Start antihypertensive therapy if target BP not achieved.
Moderate risk: BP <180/110 mmHg, 1-2 risk factors, no diabetes, TOD and/or ACC.
  • Lifestyle modification for 3-6 months.
  • Start antihypertensive therapy if target BP not achieved.
High or very high risk: BP >140/90 mmHg with 3 or more risk factors, diabetes, TOD and/or ACC. Lifestyle modification with immediate antihypertensive therapy.
  • Low dose thiazide diuretic e.g:
    • Hydrochlorothiazide, oral, 12.5 mg daily.
If target blood pressure is not reached after one month despite adequate adherence, add one of the following: ACE inhibitor or a calcium channel blocker.
  • ACE inhibitor, e.g:
    • Enalapril, oral, 10 mg daily.
OR
  • Long-acting calcium channel blocker, e.g:
    • Amlodipine, oral, 5 mg daily.
  • If target blood pressure is not reached after one month despite adequate adherence, add one of ACE inhibitor or calcium channel blocker, whichever has not already been used.
  • If target blood pressure is not reached after one month despite adequate adherence, add a blocker.
blocker , e.g:
  • Atenolol, oral, 50 mg daily.
If target blood pressure is not achieved after one month despite adequate adherence, increase the dose of drugs, one drug every month, to their maximal levels: enalapril 10 mg 12 hourly, amlodipine 10 mg daily and hydrochlorothiazide 25 mg daily.
Note:
  • In 60-80% of patients a combination of the above antihypertensive therapy is needed. Combination therapy, i.e. hydrochlorothiazide plus a calcium channel blocker or ACE inhibitor should be considered at the outset in patients with BP >160/100 mmHg.
Risk assessment: 10 year risk of MI > 20%:
  • HMGCoA reductase inhibitors e.g:
    • Simvastatin, oral, 10 mg daily.
    • This therapy requires good initial evaluation, ongoing support for patients and continuous evaluation to ensure compliance.
    • Therapy should be initiated together with appropriate lifestyle modification and adherence monitoring.
Indication for lipid-lowering drug therapy
  • Established atherosclerotic disease, irrespective of cholesterol or triglyceride plasma concentrations:
    • Ischaemic heart disease,
    • Peripheral vascular disease, or
    • Atherothrombotic stroke.
  • Type 2 diabetics > 40 years of age.
  • Chronic kidney disease (eGFR < 60 mL / minute.)
  • A risk of MI of greater than 20% in 10 years
Such high-risk patients will benefit from lipid-lowering (statin) therapy irrespective of their baseline LDL-C levels.
  • HMGCoA reductase inhibitors (statins) that lower LDL by at least 25%, e.g:
    • Simvastatin, oral, 10 mg at night.
Note:
  • This is always in conjunction with ongoing lifestyle modifications when lipid-lowering drugs are used.


When to refer:
  • Referral is dynamic and patients can be referred up to a specialist or down to PHC when controlled. Consultation without Referral may be all that is necessary.
Referrals are indicated when:
  • Patients are compliant with therapy, and the blood pressure is refractory, i.e. >140/90 mmHg, while on drugs from three to four different classes at the appropriate dose, one of which is a diuretic.
  • All cases where secondary hypertension is suspected.
  • Complicated hypertensive urgency e.g. malignant/accelerated hypertension, severe heart failure with hypertension and hypertensive emergency.